Abstracts
OBJECTIVE:
To systematically review the available evidence on the efficacy of walking training associated with virtual reality-based training in patients with stroke. The specific questions were: Is walking training associated with virtual reality-based training effective in increasing walking speed after stroke? Is this type of intervention more effective in increasing walking speed, than non-virtual reality-based walking interventions?
METHOD:
A systematic review with meta-analysis of randomized clinical trials was conducted. Participants were adults with chronic stroke and the experimental intervention was walking training associated with virtual reality-based training to increase walking speed. The outcome data regarding walking speed were extracted from the eligible trials and were combined using a meta-analysis approach.
RESULTS:
Seven trials representing eight comparisons were included in this systematic review. Overall, the virtual reality-based training increased walking speed by 0.17 m/s (IC 95% 0.08 to 0.26), compared with placebo/nothing or non-walking interventions. In addition, the virtual reality-based training increased walking speed by 0.15 m/s (IC 95% 0.05 to 0.24), compared with non-virtual reality walking interventions.
CONCLUSIONS:
This review provided evidence that walking training associated with virtual reality-based training was effective in increasing walking speed after stroke, and resulted in better results than non-virtual reality interventions.
OBJETIVO:
Revisar estudos sobre a eficácia do treino direcionado à marcha associado à realidade virtual em pacientes pós-acidente vascular encefálico (AVE). As perguntas clínicas foram: o treino direcionado à marcha associado à realidade virtual é eficaz para promover aumento em velocidade de marcha de indivíduos com hemiparesia? Essa modalidade de intervenção promove maior aumento em velocidade de marcha comparada a outras intervenções sem uso de realidade virtual?
MÉTODO:
Foi realizada uma revisão sistemática com metanálise de ensaios clínicos aleatorizados. Os participantes eram adultos pós-AVE, e a intervenção experimental considerada foi o treino direcionado à marcha associado ao uso de realidade virtual com o objetivo de melhorar a velocidade de marcha. Os dados referentes à velocidade de marcha foram extraídos para combinação por metanálise.
RESULTADOS:
Sete estudos representando oito comparações foram incluídos nesta revisão sistemática. O treino de marcha associado à realidade virtual aumentou a velocidade de marcha dos participantes, em média, 0,17 m/s (IC 95% 0,08 a 0,26) comparado à intervenção placebo, não intervenção ou intervenção não específica para os membros inferiores. Adicionalmente, o treino associado à realidade virtual aumentou a velocidade de marcha dos participantes, em média, 0,15 m/s (IC 95% 0,05 a 0,24) comparado a diferentes intervenções destinadas aos membros inferiores sem uso de realidade virtual associada.
CONCLUSÕES:
Esta revisão sistemática apresentou evidência clínica de que a adição da realidade virtual ao treino de marcha demonstrou ser eficaz para aumentar a velocidade de marcha de indivíduos com hemiparesia e apresentou melhores resultados, quando se compara a outras intervenções sem uso de realidade virtual.
Introduction
After stroke, individuals often exhibit motor impairments, which are associated with
activity limitations and social participation restrictions. Walking limitations is one of
the main causes of disabilities after stroke, as the ability to walk is directly related to
functional independence11. Horvath M, Tihanyi T, Tihanyi J. Kinematic and kinetic analyses of gait
patterns in hemiplegic patients. Facta Univ. 2011;1(8):25-35.
,
22. Robinson CA, Shumway-Cook A, Matsuda PN, Ciol MA. Understanding physical
factors associated with participation in community ambulation following stroke. Disabil
Rehabil. 2011;33(12):1033-42. http://dx.doi.org/10.3109/09638288.2010.520803.
PMid:20923316.
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. According to Alzahrani et al.33. Alzahrani M, Dean C, Ada L. Relationship between walking performance and
types of community-based activities in people with stroke: an observational study. Rev
Bras Fisioter. 2011;15(1):45-51. http://dx.doi.org/10.1590/S1413-35552011005000002.
PMid:21390472.
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, if walking performance is poor after stroke, activities at home and in
the community will be limited, so that people may become housebound and isolated from
society.
The mean walking speed after stroke varies from 0.4 to 0.8 m/s44. Schmid A, Duncan PW, Studenski S, Lai SM, Richards L, Perera S, et al.
Improvements in speed-based gait classifications are meaningful. Stroke.
2007;38(7):2096-100. http://dx.doi.org/10.1161/STROKEAHA.106.475921.
PMid:17510461
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5. Ada L, Dean CM, Vargas J, Ennis S. Mechanically assisted walking with
body weight support results in more independent walking than assisted overground walking
in non-ambulatory patients early after stroke: a systematic review. J Physiother.
2010;56(3):153-61. http://dx.doi.org/10.1016/S1836-9553(10)70020-5.
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66. Polese JC, Ada L, Dean CM, Nascimento LR, Teixeira-Salmela LF. Treadmill
training is effective for ambulatory adults with stroke: a systematic review. J
Physiother. 2013;59(2):73-80. http://dx.doi.org/10.1016/S1836-9553(13)70159-0.
PMid:23663792.
https://doi.org/10.1016/S1836-9553(13)70...
. Walking speeds of less than 0.4 m/s define
household ambulation; speeds between 0.4 and 0.8 m/s define limited community ambulation;
and speeds greater than 0.8 m/s define full community ambulation. Consequently, a
significant focus of interest in rehabilitation trials is to identify the effectiveness of
interventions, which are able to increase walking speed after stroke, as greater speed is
related to improved social participation and quality of life33. Alzahrani M, Dean C, Ada L. Relationship between walking performance and
types of community-based activities in people with stroke: an observational study. Rev
Bras Fisioter. 2011;15(1):45-51. http://dx.doi.org/10.1590/S1413-35552011005000002.
PMid:21390472.
https://doi.org/10.1590/S1413-3555201100...
,
44. Schmid A, Duncan PW, Studenski S, Lai SM, Richards L, Perera S, et al.
Improvements in speed-based gait classifications are meaningful. Stroke.
2007;38(7):2096-100. http://dx.doi.org/10.1161/STROKEAHA.106.475921.
PMid:17510461
https://doi.org/10.1161/STROKEAHA.106.47...
. Although previous systematic reviews have evidenced
the efficacy of both overground and treadmill training in improving walking speed55. Ada L, Dean CM, Vargas J, Ennis S. Mechanically assisted walking with
body weight support results in more independent walking than assisted overground walking
in non-ambulatory patients early after stroke: a systematic review. J Physiother.
2010;56(3):153-61. http://dx.doi.org/10.1016/S1836-9553(10)70020-5.
PMid:20795921.
https://doi.org/10.1016/S1836-9553(10)70...
6. Polese JC, Ada L, Dean CM, Nascimento LR, Teixeira-Salmela LF. Treadmill
training is effective for ambulatory adults with stroke: a systematic review. J
Physiother. 2013;59(2):73-80. http://dx.doi.org/10.1016/S1836-9553(13)70159-0.
PMid:23663792.
https://doi.org/10.1016/S1836-9553(13)70...
-
77. States RA, Salem Y, Pappas E. Overground gait training for individuals
with chronic stroke: a Cochrane systematic review. J Neurol Phys Ther. 2009;33(4):179-86.
http://dx.doi.org/10.1097/NPT.0b013e3181c29a8c. PMid:20208461.
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, new techniques and instruments can be added to
usual walking training, to optimize the effect of interventions aimed at improving walking
ability after stroke.
Some studies have suggested that virtual reality might be a useful tool in the
rehabilitation of individuals after stroke, and its effect on walking speed have started
being investigated88. Laver KE, George S, Thomas S, Deutsch JE, Crotty M. Virtual reality for
stroke rehabilitation. Cochrane Database Syst Rev. 2011;9:CD008349.
http://dx.doi.org/10.1002/14651858.CD008349.pub2. PMid:21901720.
https://doi.org/10.1002/14651858.CD00834...
9. Moreira MC, de Amorim Lima AM, Ferraz KM, Benedetti Rodrigues MA. Use of
virtual reality in gait recovery among post stroke patients-a systematic literature
review. Disabil Rehabil Assist Technol. 2013;8(5):357-62.
http://dx.doi.org/10.3109/17483107.2012.749428. PMid:23614694.
https://doi.org/10.3109/17483107.2012.74...
10. Mouawad MR, Doust CG, Max MD, McNulty PA. Wii-based movement therapy to
promote improved upper extremity function post-stroke: a pilot study. J Rehabil Med.
2011;43(6):527-33. http://dx.doi.org/10.2340/16501977-0816.
PMid:21533334.
https://doi.org/10.2340/16501977-0816...
-
1111. Saposnik G, Levin M, Outcome Research Canada (SORCan) Working Group.
Virtual reality in stroke rehabilitation: a meta-analysis and implications for clinicians.
Stroke. 2011;42(5):1380-6. http://dx.doi.org/10.1161/STROKEAHA.110.605451.
PMid:21474804.
https://doi.org/10.1161/STROKEAHA.110.60...
. By definition, virtual reality is the use of
interactive simulations created with computer hardware and software to provide users with
opportunities to engage in environments that appear and feel similar to real-world objects
and events55. Ada L, Dean CM, Vargas J, Ennis S. Mechanically assisted walking with
body weight support results in more independent walking than assisted overground walking
in non-ambulatory patients early after stroke: a systematic review. J Physiother.
2010;56(3):153-61. http://dx.doi.org/10.1016/S1836-9553(10)70020-5.
PMid:20795921.
https://doi.org/10.1016/S1836-9553(10)70...
. A wide variety of interfaces that allow
the interactions with virtual environments is currently available. Components may be common
devices, such as mouse, keyboards or joysticks, or more complex systems with cameras,
sensors, and feedback devices, providing the users with the sensation of touching targets or
deviating from objects, which are similar to obstacles present in the real world1111. Saposnik G, Levin M, Outcome Research Canada (SORCan) Working Group.
Virtual reality in stroke rehabilitation: a meta-analysis and implications for clinicians.
Stroke. 2011;42(5):1380-6. http://dx.doi.org/10.1161/STROKEAHA.110.605451.
PMid:21474804.
https://doi.org/10.1161/STROKEAHA.110.60...
,
1212. Peñasco-Martín B, de los Reyes-Guzmán A, Gil-Agudo Á, Bernal-Sahún A,
Pérez-Aguilar B, de la Peña-González AI. Application of virtual reality in the motor
aspects of neurorehabilitation. Rev Neurol. 2010;51(8):481-8.
PMid:20925030..
According to Dobkin1313. Dobkin BH. Strategies for stroke rehabilitation. Lancet Neurol.
2004;3(9):528-36. http://dx.doi.org/10.1016/S1474-4422(04)00851-8.
PMid:15324721.
https://doi.org/10.1016/S1474-4422(04)00...
, the addition of virtual
reality elements to walking interventions is advantageous, as it provides training in an
enriched environment similar to the real environment patients experience in daily life. In
addition, virtual tasks have been described as more interesting and enjoyable by both
children and adults, thereby, encouraging more time of practice and higher number of
repetitions, which are considered to be important factors in the rehabilitation of
individuals with neurologic disorders88. Laver KE, George S, Thomas S, Deutsch JE, Crotty M. Virtual reality for
stroke rehabilitation. Cochrane Database Syst Rev. 2011;9:CD008349.
http://dx.doi.org/10.1002/14651858.CD008349.pub2. PMid:21901720.
https://doi.org/10.1002/14651858.CD00834...
,
1414. Thornton M, Marshall S, McComas J, Finestone H, McCormick A, Sveistrup
H. Benefits of activity and virtual reality based balance exercise programmes for adults
with traumatic brain injury: perceptions of participants and their caregivers. Brain Inj.
2005;19(12):989-1000. http://dx.doi.org/10.1080/02699050500109944.
PMid:16263641.
https://doi.org/10.1080/0269905050010994...
. Concerning walking rehabilitation, the use of
virtual environments enables therapists to progressively modulate the levels of difficulty
of the tasks to challenge patients and to provide them with immediate feedback regarding
their performance. Furthermore, clinicians are able to train tasks that are unsafe to
practice in the real world, such as overcoming obstacles or crossing streets88. Laver KE, George S, Thomas S, Deutsch JE, Crotty M. Virtual reality for
stroke rehabilitation. Cochrane Database Syst Rev. 2011;9:CD008349.
http://dx.doi.org/10.1002/14651858.CD008349.pub2. PMid:21901720.
https://doi.org/10.1002/14651858.CD00834...
,
1313. Dobkin BH. Strategies for stroke rehabilitation. Lancet Neurol.
2004;3(9):528-36. http://dx.doi.org/10.1016/S1474-4422(04)00851-8.
PMid:15324721.
https://doi.org/10.1016/S1474-4422(04)00...
.
Two previous systematic reviews have examined the effect of walking training associated
with virtual reality-based training in improving walking ability after stroke. A
Cochrane
88. Laver KE, George S, Thomas S, Deutsch JE, Crotty M. Virtual reality for
stroke rehabilitation. Cochrane Database Syst Rev. 2011;9:CD008349.
http://dx.doi.org/10.1002/14651858.CD008349.pub2. PMid:21901720.
https://doi.org/10.1002/14651858.CD00834...
review reported a non-significant increase in
walking speed of 0.07 m/s (95% CI:-0.09 to 0.23), based upon three randomised clinical
trials. A more recent review99. Moreira MC, de Amorim Lima AM, Ferraz KM, Benedetti Rodrigues MA. Use of
virtual reality in gait recovery among post stroke patients-a systematic literature
review. Disabil Rehabil Assist Technol. 2013;8(5):357-62.
http://dx.doi.org/10.3109/17483107.2012.749428. PMid:23614694.
https://doi.org/10.3109/17483107.2012.74...
included four randomised
clinical trials and indicated that the addition of virtual reality-based training was
beneficial to walking ability after stroke. However, the authors reported clinical
heterogeneity between the trials, and a meta-analysis was not performed. Therefore, the
results regarding the addition of virtual reality-based training to walking interventions
aimed at improving walking ability after stroke remain inconclusive. In addition, there were
not found any reviews that separately examined the efficacy of walking training associated
with virtual reality-based training and the superiority of this association, compared with
other walking interventions.
Therefore, the aim of this systematic review was to examine the effect of the addition of virtual reality-based training to walking training for improving walking speed after stroke. The specific research questions were:
-
Is walking training associated with virtual reality-based training effective in increasing walking speed after stroke?
-
Is walking training associated with virtual reality-based training more effective than non-virtual reality-based interventions?
In order to make recommendations based upon a high level of evidence, this review planned to include only randomised or controlled trials.
Method
Identification and selection of trials
Searches were conducted at the MEDLINE (1946 to July 2013), PEDro (to July 2013), and EMBASE (1980 to July 2013) databases for relevant studies without language restrictions. Search terms included words related to stroke, virtual reality training (such as virtual reality, video-games, flow optic) and gait (Appendix 1). Titles and abstracts were displayed and screened by one reviewer to identify relevant studies. Full paper copies of relevant peer-reviewed papers were retrieved and their reference lists were also screened to identify further relevant studies. The selection of the retrieved papers was conducted by two reviewers, using predetermined criteria, which are summarized in the supplementary materials related to this paper (Appendix 1S[1]).
Assessment of characteristics of the trials
Quality: The quality of the included trials was assessed by extracting PEDro scores
from the Physiotherapy Evidence Database1515. Physiotherapy Evidence Database [Internet]. 2011. [cited 2011 May 25].
Available from: http://www pedro org
au/portuguese/downloads/pedro-scale/.
http://www
pedro org au/po...
. PEDro
is an 11-item scale designed for rating the methodological quality (internal validity and
statistical information) of randomised trials. Each item, except for Item 1, contributes
one point to the total score (range: 0 to 10 points). Where a trial was not included on
the database, it was scored by a reviewer, who had completed the PEDro scale training
tutorial.
Participants: Trials involving ambulatory adults after stroke were included. The number of participants, age, time since stroke, and baseline walking speed were recorded to assess the similarity of the studies.
Intervention: The experimental intervention was walking training associated with virtual
reality-based training aimed at improving walking speed after stroke. Virtual reality was
defined as a simulation of a real environment created by a computer software which allowed
users to interact with elements within a simulated scenario by using different interfaces,
such as mouse, keyboards, joysticks, gloves, and/or motion capture systems1111. Saposnik G, Levin M, Outcome Research Canada (SORCan) Working Group.
Virtual reality in stroke rehabilitation: a meta-analysis and implications for clinicians.
Stroke. 2011;42(5):1380-6. http://dx.doi.org/10.1161/STROKEAHA.110.605451.
PMid:21474804.
https://doi.org/10.1161/STROKEAHA.110.60...
,
1212. Peñasco-Martín B, de los Reyes-Guzmán A, Gil-Agudo Á, Bernal-Sahún A,
Pérez-Aguilar B, de la Peña-González AI. Application of virtual reality in the motor
aspects of neurorehabilitation. Rev Neurol. 2010;51(8):481-8.
PMid:20925030.. We included trials using any form of
non-immersive or immersive virtual reality, and those that used commercially available
gaming consoles88. Laver KE, George S, Thomas S, Deutsch JE, Crotty M. Virtual reality for
stroke rehabilitation. Cochrane Database Syst Rev. 2011;9:CD008349.
http://dx.doi.org/10.1002/14651858.CD008349.pub2. PMid:21901720.
https://doi.org/10.1002/14651858.CD00834...
.
The control intervention was defined according to the research questions: (i) to examine the efficacy of walking training associated with virtual reality-based training, the control intervention could be nothing/placebo or any other non-walking intervention; (ii) to examine the superiority of walking training associated with virtual reality-based training, the control intervention could be any other non-virtual reality walking intervention.
Outcome measure: The outcome measure of interest was comfortable walking speed, provided, in this review, in meters per second (m/s). The timing of the measurements and the procedure used to measure walking speed were recorded to assess the appropriateness of combining the studies in a meta-analysis.
Data analysis
Information about the method (i.e., design, participants, interventions, and outcome measures) and results (i.e., number of participants, and means (SD) of walking speed) were extracted by one reviewer and checked by a second one. Where information was not available in the published trials, details were requested from the corresponding author.
The post-intervention scores were used to obtain the pooled estimate of the effect of
intervention. The effect size was obtained using the fixed effects model and reported as
weighted mean differences (MD) with 95% confidence intervals (95% CI). In the
case of significant statistical heterogeneity (I2>50%), a random effects
model was applied to check the robustness of the results. The analyses were performed
using the MIX-Meta-Analysis Made Easy program Version 1.71616. Bax L, Yu LM, Ikeda N, Tsuruta H, Moons KG. Development and validation
of MIX: comprehensive free software for meta-analysis of causal research data. BMC Med Res
Methodol. 2006;6(1):50. http://dx.doi.org/10.1186/1471-2288-6-50.
PMid:17038197.
https://doi.org/10.1186/1471-2288-6-50...
,
1717. Bax L, Ikeda N, Fukui N, Yaju Y, Tsuruta H, Moons KG. More than numbers:
the power of graphs in meta-analysis. Am J Epidemiol. 2009;169(2):249-55.
http://dx.doi.org/10.1093/aje/kwn340. PMid:19064649.
https://doi.org/10.1093/aje/kwn340...
; the significance level for statistical
heterogeneity was set at 5% (two-tailed). Where data were not available to be included in
the pooled analysis, the between-group results were reported.
Results
Flow of trials through the review
The electronic search strategy identified 999 relevant papers for the analysis of titles
and abstracts. After screening titles and abstracts, 15 potentially relevant full papers
to answer the research questions were retrieved. Following the analysis, according to the
predetermined inclusion criteria, eight papers were retrieved. After data extraction, one
paper1818. Mirelman A, Patritti BL, Bonato P, Deutsch JE. Effects of virtual
reality training on gait biomechanics of individuals post-stroke. Gait Posture.
2010;31(4):433-7. http://dx.doi.org/10.1016/j.gaitpost.2010.01.016.
PMid:20189810.
https://doi.org/10.1016/j.gaitpost.2010....
was removed from the review, because its
results included duplicate data of a second paper1919. Mirelman A, Bonato P, Deutsch JE. Effects of training with a
robot-virtual reality system compared with a robot alone on the gait of individuals after
stroke. Stroke. 2009;40(1):169-74. http://dx.doi.org/10.1161/STROKEAHA.108.516328.
PMid:18988916.
https://doi.org/10.1161/STROKEAHA.108.51...
. Therefore, seven papers were included in this review (Figure 1).
Characteristics of the included trials
Seven randomized clinical trials involving 154 participants examined the efficacy of
walking training associated with virtual reality-based training for increasing walking
speed after stroke, and therefore were included in this review (Table 1). Since one of the trials2020. Kang HK, Kim Y, Chung Y, Hwang S. Effects of treadmill training with
optic flow on balance and gait in individuals following stroke: randomized controlled
trials. Clin Rehabil. 2012;26(3):246-55. http://dx.doi.org/10.1177/0269215511419383.
PMid:21971754.
https://doi.org/10.1177/0269215511419383...
included two control groups, a total of eight comparisons were performed.
Three trials2020. Kang HK, Kim Y, Chung Y, Hwang S. Effects of treadmill training with
optic flow on balance and gait in individuals following stroke: randomized controlled
trials. Clin Rehabil. 2012;26(3):246-55. http://dx.doi.org/10.1177/0269215511419383.
PMid:21971754.
https://doi.org/10.1177/0269215511419383...
21. Fritz SL, Peters DM, Merlo AM, Donley J. Active video-gaming effects on
balance and mobility in individuals with chronic stroke: a randomized controlled trial.
Top Stroke Rehabil. 2013;20(3):218-25. http://dx.doi.org/10.1310/tsr2003-218.
PMid:23841969.
https://doi.org/10.1310/tsr2003-218...
-
2222. Kim JH, Jang SH, Kim CS, Jung JH, You JH. Use of virtual reality to
enhance balance and ambulation in chronic stroke: a double-blind, randomized controlled
study. Am J Phys Med Rehabil. 2009;88(9):693-701.
http://dx.doi.org/10.1097/PHM.0b013e3181b33350. PMid:19692788.
https://doi.org/10.1097/PHM.0b013e3181b3...
compared walking training associated with
virtual reality-based training with nothing/placebo or non-walking intervention (Question
1). Five trials1919. Mirelman A, Bonato P, Deutsch JE. Effects of training with a
robot-virtual reality system compared with a robot alone on the gait of individuals after
stroke. Stroke. 2009;40(1):169-74. http://dx.doi.org/10.1161/STROKEAHA.108.516328.
PMid:18988916.
https://doi.org/10.1161/STROKEAHA.108.51...
,
2020. Kang HK, Kim Y, Chung Y, Hwang S. Effects of treadmill training with
optic flow on balance and gait in individuals following stroke: randomized controlled
trials. Clin Rehabil. 2012;26(3):246-55. http://dx.doi.org/10.1177/0269215511419383.
PMid:21971754.
https://doi.org/10.1177/0269215511419383...
,
2323. Cho KH, Lee WH. Virtual walking training program using a real-world
video recording for patients with chronic stroke: a pilot study. Am J Phys Med Rehabil.
2013;92(5):371-80. http://dx.doi.org/10.1097/PHM.0b013e31828cd5d3.
PMid:23598900.
https://doi.org/10.1097/PHM.0b013e31828c...
24. Jaffe DL, Brown DA, Pierson-Carey CD, Buckley EL, Lew HL. Stepping over
obstacles to improve walking in individuals with poststroke hemiplegia. J Rehabil Res Dev.
2004;41(3A):283-92. http://dx.doi.org/10.1682/JRRD.2004.03.0283.
PMid:15543446.
https://doi.org/10.1682/JRRD.2004.03.028...
-
2525. Yang YR, Tsai MP, Chuang TY, Sung WH, Wang RY. Virtual reality-based
training improves community ambulation in individuals with stroke: a randomized controlled
trial. Gait Posture. 2008;28(2):201-6. http://dx.doi.org/10.1016/j.gaitpost.2007.11.007.
PMid:18358724.
https://doi.org/10.1016/j.gaitpost.2007....
compared walking training associated with
virtual reality-based training with a non-virtual reality walking intervention (Question
2).
Quality: The mean PEDro score of the included trials was 6.1, ranging from 4 to 8 points (Table 2). All the trials randomly allocated participants, had similar groups at baseline, and reported point estimate and variability. The majority of trials reported concealed allocation (57%), had less than 15% drop-outs (57%), reported between-group differences (86%), and had blinded assessors (86%). However, the majority of trials did not report whether and intention-to-treat analysis was undertaken (86%). Only one trial22 blinded participants, and no trials blinded therapists, which is considered difficult or impossible during complex interventions.
Participants: The mean age of participants ranged from 52 to 66 years across trials. All trials included participants with time after stroke greater than six months (ranging from 10 to 72 months across trials), which defines chronic hemiparesis. The sample size of the included trials ranged between 14 and 30 participants, who were allocated to the experimental or control groups. All of the participants were ambulatory adults at the time of entry into the trial, with mean baseline walking speed ranging from 0.46 to 0.70 m/s across trials.
Intervention: In all trials, the experimental intervention was walking training
associated with virtual reality-based training. Virtual reality-based training was
associated with treadmill training in four trials2020. Kang HK, Kim Y, Chung Y, Hwang S. Effects of treadmill training with
optic flow on balance and gait in individuals following stroke: randomized controlled
trials. Clin Rehabil. 2012;26(3):246-55. http://dx.doi.org/10.1177/0269215511419383.
PMid:21971754.
https://doi.org/10.1177/0269215511419383...
,
2323. Cho KH, Lee WH. Virtual walking training program using a real-world
video recording for patients with chronic stroke: a pilot study. Am J Phys Med Rehabil.
2013;92(5):371-80. http://dx.doi.org/10.1097/PHM.0b013e31828cd5d3.
PMid:23598900.
https://doi.org/10.1097/PHM.0b013e31828c...
24. Jaffe DL, Brown DA, Pierson-Carey CD, Buckley EL, Lew HL. Stepping over
obstacles to improve walking in individuals with poststroke hemiplegia. J Rehabil Res Dev.
2004;41(3A):283-92. http://dx.doi.org/10.1682/JRRD.2004.03.0283.
PMid:15543446.
https://doi.org/10.1682/JRRD.2004.03.028...
-
2525. Yang YR, Tsai MP, Chuang TY, Sung WH, Wang RY. Virtual reality-based
training improves community ambulation in individuals with stroke: a randomized controlled
trial. Gait Posture. 2008;28(2):201-6. http://dx.doi.org/10.1016/j.gaitpost.2007.11.007.
PMid:18358724.
https://doi.org/10.1016/j.gaitpost.2007....
, with video-games exercises in two trials2121. Fritz SL, Peters DM, Merlo AM, Donley J. Active video-gaming effects on
balance and mobility in individuals with chronic stroke: a randomized controlled trial.
Top Stroke Rehabil. 2013;20(3):218-25. http://dx.doi.org/10.1310/tsr2003-218.
PMid:23841969.
https://doi.org/10.1310/tsr2003-218...
,
2222. Kim JH, Jang SH, Kim CS, Jung JH, You JH. Use of virtual reality to
enhance balance and ambulation in chronic stroke: a double-blind, randomized controlled
study. Am J Phys Med Rehabil. 2009;88(9):693-701.
http://dx.doi.org/10.1097/PHM.0b013e3181b33350. PMid:19692788.
https://doi.org/10.1097/PHM.0b013e3181b3...
, and with kinesiotherapy involving specific
ankle movements in one trial1919. Mirelman A, Bonato P, Deutsch JE. Effects of training with a
robot-virtual reality system compared with a robot alone on the gait of individuals after
stroke. Stroke. 2009;40(1):169-74. http://dx.doi.org/10.1161/STROKEAHA.108.516328.
PMid:18988916.
https://doi.org/10.1161/STROKEAHA.108.51...
. Three trials2020. Kang HK, Kim Y, Chung Y, Hwang S. Effects of treadmill training with
optic flow on balance and gait in individuals following stroke: randomized controlled
trials. Clin Rehabil. 2012;26(3):246-55. http://dx.doi.org/10.1177/0269215511419383.
PMid:21971754.
https://doi.org/10.1177/0269215511419383...
,
2222. Kim JH, Jang SH, Kim CS, Jung JH, You JH. Use of virtual reality to
enhance balance and ambulation in chronic stroke: a double-blind, randomized controlled
study. Am J Phys Med Rehabil. 2009;88(9):693-701.
http://dx.doi.org/10.1097/PHM.0b013e3181b33350. PMid:19692788.
https://doi.org/10.1097/PHM.0b013e3181b3...
,
2323. Cho KH, Lee WH. Virtual walking training program using a real-world
video recording for patients with chronic stroke: a pilot study. Am J Phys Med Rehabil.
2013;92(5):371-80. http://dx.doi.org/10.1097/PHM.0b013e31828cd5d3.
PMid:23598900.
https://doi.org/10.1097/PHM.0b013e31828c...
delivered usual therapy to both experimental and
control groups.
The majority of trials delivered immersive virtual reality training to the experimental
group. In these trials2020. Kang HK, Kim Y, Chung Y, Hwang S. Effects of treadmill training with
optic flow on balance and gait in individuals following stroke: randomized controlled
trials. Clin Rehabil. 2012;26(3):246-55. http://dx.doi.org/10.1177/0269215511419383.
PMid:21971754.
https://doi.org/10.1177/0269215511419383...
,
2323. Cho KH, Lee WH. Virtual walking training program using a real-world
video recording for patients with chronic stroke: a pilot study. Am J Phys Med Rehabil.
2013;92(5):371-80. http://dx.doi.org/10.1097/PHM.0b013e31828cd5d3.
PMid:23598900.
https://doi.org/10.1097/PHM.0b013e31828c...
24. Jaffe DL, Brown DA, Pierson-Carey CD, Buckley EL, Lew HL. Stepping over
obstacles to improve walking in individuals with poststroke hemiplegia. J Rehabil Res Dev.
2004;41(3A):283-92. http://dx.doi.org/10.1682/JRRD.2004.03.0283.
PMid:15543446.
https://doi.org/10.1682/JRRD.2004.03.028...
-
2525. Yang YR, Tsai MP, Chuang TY, Sung WH, Wang RY. Virtual reality-based
training improves community ambulation in individuals with stroke: a randomized controlled
trial. Gait Posture. 2008;28(2):201-6. http://dx.doi.org/10.1016/j.gaitpost.2007.11.007.
PMid:18358724.
https://doi.org/10.1016/j.gaitpost.2007....
, virtual images were coupled to the treadmill,
and treadmill speed was changed as a function of the generated visual images.
Non-immersive virtual reality was used in three trials1919. Mirelman A, Bonato P, Deutsch JE. Effects of training with a
robot-virtual reality system compared with a robot alone on the gait of individuals after
stroke. Stroke. 2009;40(1):169-74. http://dx.doi.org/10.1161/STROKEAHA.108.516328.
PMid:18988916.
https://doi.org/10.1161/STROKEAHA.108.51...
,
2121. Fritz SL, Peters DM, Merlo AM, Donley J. Active video-gaming effects on
balance and mobility in individuals with chronic stroke: a randomized controlled trial.
Top Stroke Rehabil. 2013;20(3):218-25. http://dx.doi.org/10.1310/tsr2003-218.
PMid:23841969.
https://doi.org/10.1310/tsr2003-218...
,
2222. Kim JH, Jang SH, Kim CS, Jung JH, You JH. Use of virtual reality to
enhance balance and ambulation in chronic stroke: a double-blind, randomized controlled
study. Am J Phys Med Rehabil. 2009;88(9):693-701.
http://dx.doi.org/10.1097/PHM.0b013e3181b33350. PMid:19692788.
https://doi.org/10.1097/PHM.0b013e3181b3...
: two2121. Fritz SL, Peters DM, Merlo AM, Donley J. Active video-gaming effects on
balance and mobility in individuals with chronic stroke: a randomized controlled trial.
Top Stroke Rehabil. 2013;20(3):218-25. http://dx.doi.org/10.1310/tsr2003-218.
PMid:23841969.
https://doi.org/10.1310/tsr2003-218...
,
2222. Kim JH, Jang SH, Kim CS, Jung JH, You JH. Use of virtual reality to
enhance balance and ambulation in chronic stroke: a double-blind, randomized controlled
study. Am J Phys Med Rehabil. 2009;88(9):693-701.
http://dx.doi.org/10.1097/PHM.0b013e3181b33350. PMid:19692788.
https://doi.org/10.1097/PHM.0b013e3181b3...
employed video cameras to capture the patient's
body image and to enable interactions with virtual objects; one trial1919. Mirelman A, Bonato P, Deutsch JE. Effects of training with a
robot-virtual reality system compared with a robot alone on the gait of individuals after
stroke. Stroke. 2009;40(1):169-74. http://dx.doi.org/10.1161/STROKEAHA.108.516328.
PMid:18988916.
https://doi.org/10.1161/STROKEAHA.108.51...
employed visual feedback on the computer screen and tactile feedback
related to the patient's movements. Only one trial2121. Fritz SL, Peters DM, Merlo AM, Donley J. Active video-gaming effects on
balance and mobility in individuals with chronic stroke: a randomized controlled trial.
Top Stroke Rehabil. 2013;20(3):218-25. http://dx.doi.org/10.1310/tsr2003-218.
PMid:23841969.
https://doi.org/10.1310/tsr2003-218...
used a commercially available virtual reality device (Nintendo
Wii) during the delivery of the experimental intervention.
Outcome measures: The majority of trials used a timed walk measure based upon
the 10-Meter Walk Test2626. Nascimento LR, Caetano LC, Freitas DC, Morais TM, Polese JC,
Teixeira-Salmela LF. Different instructions during the ten-meter walking test determined
significant increases in maximum gait speed in individuals with chronic hemiparesis. Rev
Bras Fisioter. 2012;16(2):122-7. http://dx.doi.org/10.1590/S1413-35552012005000008.
PMid:22378478.
https://doi.org/10.1590/S1413-3555201200...
to measure walking speed,
with variations on the length of the corridor: 122525. Yang YR, Tsai MP, Chuang TY, Sung WH, Wang RY. Virtual reality-based
training improves community ambulation in individuals with stroke: a randomized controlled
trial. Gait Posture. 2008;28(2):201-6. http://dx.doi.org/10.1016/j.gaitpost.2007.11.007.
PMid:18358724.
https://doi.org/10.1016/j.gaitpost.2007....
, 102020. Kang HK, Kim Y, Chung Y, Hwang S. Effects of treadmill training with
optic flow on balance and gait in individuals following stroke: randomized controlled
trials. Clin Rehabil. 2012;26(3):246-55. http://dx.doi.org/10.1177/0269215511419383.
PMid:21971754.
https://doi.org/10.1177/0269215511419383...
,
2222. Kim JH, Jang SH, Kim CS, Jung JH, You JH. Use of virtual reality to
enhance balance and ambulation in chronic stroke: a double-blind, randomized controlled
study. Am J Phys Med Rehabil. 2009;88(9):693-701.
http://dx.doi.org/10.1097/PHM.0b013e3181b33350. PMid:19692788.
https://doi.org/10.1097/PHM.0b013e3181b3...
, seven1919. Mirelman A, Bonato P, Deutsch JE. Effects of training with a
robot-virtual reality system compared with a robot alone on the gait of individuals after
stroke. Stroke. 2009;40(1):169-74. http://dx.doi.org/10.1161/STROKEAHA.108.516328.
PMid:18988916.
https://doi.org/10.1161/STROKEAHA.108.51...
,
six2424. Jaffe DL, Brown DA, Pierson-Carey CD, Buckley EL, Lew HL. Stepping over
obstacles to improve walking in individuals with poststroke hemiplegia. J Rehabil Res Dev.
2004;41(3A):283-92. http://dx.doi.org/10.1682/JRRD.2004.03.0283.
PMid:15543446.
https://doi.org/10.1682/JRRD.2004.03.028...
, and three meters2121. Fritz SL, Peters DM, Merlo AM, Donley J. Active video-gaming effects on
balance and mobility in individuals with chronic stroke: a randomized controlled trial.
Top Stroke Rehabil. 2013;20(3):218-25. http://dx.doi.org/10.1310/tsr2003-218.
PMid:23841969.
https://doi.org/10.1310/tsr2003-218...
. One trial2323. Cho KH, Lee WH. Virtual walking training program using a real-world
video recording for patients with chronic stroke: a pilot study. Am J Phys Med Rehabil.
2013;92(5):371-80. http://dx.doi.org/10.1097/PHM.0b013e31828cd5d3.
PMid:23598900.
https://doi.org/10.1097/PHM.0b013e31828c...
used foot
sensors during a timed walk test from a specific device (GAITRite; CIR System Inc, New
Jersey) to measure walking speed. All the data in this review reflects comfortable gait
speed and were converted to m/s.
Effect of walking training associated with virtual reality-based training on walking speed
The overall effect of walking training associated with virtual reality-based training on
walking speed immediately after intervention was examined by pooling post-intervention
data from three trials2020. Kang HK, Kim Y, Chung Y, Hwang S. Effects of treadmill training with
optic flow on balance and gait in individuals following stroke: randomized controlled
trials. Clin Rehabil. 2012;26(3):246-55. http://dx.doi.org/10.1177/0269215511419383.
PMid:21971754.
https://doi.org/10.1177/0269215511419383...
21. Fritz SL, Peters DM, Merlo AM, Donley J. Active video-gaming effects on
balance and mobility in individuals with chronic stroke: a randomized controlled trial.
Top Stroke Rehabil. 2013;20(3):218-25. http://dx.doi.org/10.1310/tsr2003-218.
PMid:23841969.
https://doi.org/10.1310/tsr2003-218...
-
2222. Kim JH, Jang SH, Kim CS, Jung JH, You JH. Use of virtual reality to
enhance balance and ambulation in chronic stroke: a double-blind, randomized controlled
study. Am J Phys Med Rehabil. 2009;88(9):693-701.
http://dx.doi.org/10.1097/PHM.0b013e3181b33350. PMid:19692788.
https://doi.org/10.1097/PHM.0b013e3181b3...
with a mean PEDro score of 7.0, indicating good
quality2727. Foley NC, Teasell RW, Bhogal SK, Doherty T, Speechley MR. The efficacy
of stroke rehabilitation: a qualitative review. Top Stroke Rehabil. 2003;10(2):1-18.
http://dx.doi.org/10.1310/AQE1-PCW1-FW9K-M01G. PMid:13680515
https://doi.org/10.1310/AQE1-PCW1-FW9K-M...
. Virtual reality-based training
increased walking speed by 0.17 m/s (95% CI 0.08 to 0.26; fixed effects
model I2=0%), compared with placebo/nothing or non-walking
interventions (Figure 2A).
Effect of walking training associated with virtual reality-based training, compared with non-virtual reality walking interventions on walking speed
The superiority of walking training associated with virtual reality-based training on
walking speed immediately after intervention was examined by pooling post-intervention
data from five trials1919. Mirelman A, Bonato P, Deutsch JE. Effects of training with a
robot-virtual reality system compared with a robot alone on the gait of individuals after
stroke. Stroke. 2009;40(1):169-74. http://dx.doi.org/10.1161/STROKEAHA.108.516328.
PMid:18988916.
https://doi.org/10.1161/STROKEAHA.108.51...
,
2020. Kang HK, Kim Y, Chung Y, Hwang S. Effects of treadmill training with
optic flow on balance and gait in individuals following stroke: randomized controlled
trials. Clin Rehabil. 2012;26(3):246-55. http://dx.doi.org/10.1177/0269215511419383.
PMid:21971754.
https://doi.org/10.1177/0269215511419383...
,
2323. Cho KH, Lee WH. Virtual walking training program using a real-world
video recording for patients with chronic stroke: a pilot study. Am J Phys Med Rehabil.
2013;92(5):371-80. http://dx.doi.org/10.1097/PHM.0b013e31828cd5d3.
PMid:23598900.
https://doi.org/10.1097/PHM.0b013e31828c...
24. Jaffe DL, Brown DA, Pierson-Carey CD, Buckley EL, Lew HL. Stepping over
obstacles to improve walking in individuals with poststroke hemiplegia. J Rehabil Res Dev.
2004;41(3A):283-92. http://dx.doi.org/10.1682/JRRD.2004.03.0283.
PMid:15543446.
https://doi.org/10.1682/JRRD.2004.03.028...
-
2525. Yang YR, Tsai MP, Chuang TY, Sung WH, Wang RY. Virtual reality-based
training improves community ambulation in individuals with stroke: a randomized controlled
trial. Gait Posture. 2008;28(2):201-6. http://dx.doi.org/10.1016/j.gaitpost.2007.11.007.
PMid:18358724.
https://doi.org/10.1016/j.gaitpost.2007....
with a mean PEDro score of 5.8, indicating
moderate quality2727. Foley NC, Teasell RW, Bhogal SK, Doherty T, Speechley MR. The efficacy
of stroke rehabilitation: a qualitative review. Top Stroke Rehabil. 2003;10(2):1-18.
http://dx.doi.org/10.1310/AQE1-PCW1-FW9K-M01G. PMid:13680515
https://doi.org/10.1310/AQE1-PCW1-FW9K-M...
. Virtual reality-based training
increased walking speed by 0.15 m/s (95% CI 0.05 to 0.24; fixed effects
model I2=0%), compared with non-virtual reality walking
interventions (Figure 2B).
Discussion
This systematic review provided clinical evidence that walking training associated with virtual reality-based training was effective in increasing walking speed after stroke. Clinically, the results indicated that the addition of virtual reality-based training is more effective than no intervention, placebo, or non-walking interventions. The results also indicated that walking training associated with virtual reality-based training produced faster walking speed, compared with non-virtual reality walking interventions.
The meta-analysis demonstrated that the addition of virtual reality-based training
increased walking speed by 0.17 m/s. This meta-analysis was the first to examine the
efficacy of this type of intervention to improve walking speed with individuals after
stroke. Importantly, these benefits appear to be clinically meaningful. For example, Tilson
et al.2828. Tilson JK, Sullivan KJ, Cen SY, Rose DK, Koradia CH, Azen SP, et al.
Meaningful gait speed improvement during the first 60 days poststroke: minimal clinically
important difference. Phys Ther. 2010;90(2):196-208.
http://dx.doi.org/10.2522/ptj.20090079. PMid:20022995.
https://doi.org/10.2522/ptj.20090079...
demonstrated that a between-group difference
in walking speed after stroke greater than 0.16 m/s resulted in improvement in the patients'
levels of disability, and suggested this value as a rehabilitation goal. The meta-analysis
also demonstrated that walking training associated with virtual reality-based training
produced 0.15 m/s faster walking, than other non-virtual walking interventions. A previous
systematic review88. Laver KE, George S, Thomas S, Deutsch JE, Crotty M. Virtual reality for
stroke rehabilitation. Cochrane Database Syst Rev. 2011;9:CD008349.
http://dx.doi.org/10.1002/14651858.CD008349.pub2. PMid:21901720.
https://doi.org/10.1002/14651858.CD00834...
have reported a non-significant
between-group difference after the addition of virtual reality-based training. The inclusion
of two extra clinical trials in the present meta-analysis increased its statistical power
and strengthens the evidence the efficacy of the addition of virtual reality-based training
for increasing walking speed after stroke.
This review examined the effect of the addition of virtual reality-based training to
various types of walking intervention after stroke. Although various types of walking
training have been employed across trials (i.e., treadmill training2020. Kang HK, Kim Y, Chung Y, Hwang S. Effects of treadmill training with
optic flow on balance and gait in individuals following stroke: randomized controlled
trials. Clin Rehabil. 2012;26(3):246-55. http://dx.doi.org/10.1177/0269215511419383.
PMid:21971754.
https://doi.org/10.1177/0269215511419383...
,
2323. Cho KH, Lee WH. Virtual walking training program using a real-world
video recording for patients with chronic stroke: a pilot study. Am J Phys Med Rehabil.
2013;92(5):371-80. http://dx.doi.org/10.1097/PHM.0b013e31828cd5d3.
PMid:23598900.
https://doi.org/10.1097/PHM.0b013e31828c...
24. Jaffe DL, Brown DA, Pierson-Carey CD, Buckley EL, Lew HL. Stepping over
obstacles to improve walking in individuals with poststroke hemiplegia. J Rehabil Res Dev.
2004;41(3A):283-92. http://dx.doi.org/10.1682/JRRD.2004.03.0283.
PMid:15543446.
https://doi.org/10.1682/JRRD.2004.03.028...
-
2525. Yang YR, Tsai MP, Chuang TY, Sung WH, Wang RY. Virtual reality-based
training improves community ambulation in individuals with stroke: a randomized controlled
trial. Gait Posture. 2008;28(2):201-6. http://dx.doi.org/10.1016/j.gaitpost.2007.11.007.
PMid:18358724.
https://doi.org/10.1016/j.gaitpost.2007....
, exercises using videogames2121. Fritz SL, Peters DM, Merlo AM, Donley J. Active video-gaming effects on
balance and mobility in individuals with chronic stroke: a randomized controlled trial.
Top Stroke Rehabil. 2013;20(3):218-25. http://dx.doi.org/10.1310/tsr2003-218.
PMid:23841969.
https://doi.org/10.1310/tsr2003-218...
,
2222. Kim JH, Jang SH, Kim CS, Jung JH, You JH. Use of virtual reality to
enhance balance and ambulation in chronic stroke: a double-blind, randomized controlled
study. Am J Phys Med Rehabil. 2009;88(9):693-701.
http://dx.doi.org/10.1097/PHM.0b013e3181b33350. PMid:19692788.
https://doi.org/10.1097/PHM.0b013e3181b3...
, or ankle exercises1919. Mirelman A, Bonato P, Deutsch JE. Effects of training with a
robot-virtual reality system compared with a robot alone on the gait of individuals after
stroke. Stroke. 2009;40(1):169-74. http://dx.doi.org/10.1161/STROKEAHA.108.516328.
PMid:18988916.
https://doi.org/10.1161/STROKEAHA.108.51...
), overall, the included trials were similar in terms of session duration (mean
41 min, SD 18), session frequency (mean 3.3/wk, SD 0.5), program duration (4 weeks, SD 1),
participants' characteristics, and aim of intervention. In addition, statistical analysis
(I2=0%) indicated that the trials were clinical and statistically similar,
which allowed for the data to be combined in meta-analyses. The data suggested similarity
across trials and indicated lack of clinical or statistical heterogeneity, supporting the
clinical evidence that the addition of virtual reality-based training is effective in
improving walking speed after stroke.
Although the improvement in walking speed was superior with the addition of virtual
reality-based training, other factors not examined in this review, such as clients' values
and expectations, clinical expertise, and costs of implementation should be taken into
consideration before deciding the most appropriate type of intervention for each client. The
gaming industry has recently released low-cost virtual reality systems, such as
Nintendo Wii, Kinect, and Playstation,
thus facilitating the access of rehabilitation centers and home users to this
technology2929. Saposnik G, Teasell R, Mamdani M, Hall J, McIlroy W, Cheung D, et al.
Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation: a
pilot randomized clinical trial and proof of principle. Stroke. 2010;41(7):1477-84.
http://dx.doi.org/10.1161/STROKEAHA.110.584979. PMid:20508185.
https://doi.org/10.1161/STROKEAHA.110.58...
,
3030. Pompeu JE, Mendes FA, Silva KG, Lobo AM, Oliveira TP, Zomignani AP, et
al. Effect of Nintendo Wii(tm)-based motor and cognitive training on activities of daily
living in patients with Parkinson's disease: a randomised clinical trial. Physiotherapy.
2012;98(3):196-204. http://dx.doi.org/10.1016/j.physio.2012.06.004.
PMid:22898575.
https://doi.org/10.1016/j.physio.2012.06...
. However, only one trial2121. Fritz SL, Peters DM, Merlo AM, Donley J. Active video-gaming effects on
balance and mobility in individuals with chronic stroke: a randomized controlled trial.
Top Stroke Rehabil. 2013;20(3):218-25. http://dx.doi.org/10.1310/tsr2003-218.
PMid:23841969.
https://doi.org/10.1310/tsr2003-218...
included in this review used commercially available devices, and the
between-group difference was not clinically significant for walking speed (mean difference:
0.04 m/s, 95% CI:-0.22 to 0.30). Subgroup analysis based upon the type of virtual reality
delivered could not be performed, because there were not enough trials. Thus, new clinical
trials examining the efficacy of the addition of virtual reality-based training using
commercially available devices are encouraged.
This review has both strengthens and limitations. A source of bias in the included trials
was lack of blinding of therapists and participants, since it is very difficult or
unpractical to blind either during the delivery of complex interventions, such as walking
training. In addition, the majority of the included trials did not report whether an
intention-to-treat analysis was carried-out. On the other hand, the mean PEDro score of 6.1
for the included trials indicated good methodological quality2727. Foley NC, Teasell RW, Bhogal SK, Doherty T, Speechley MR. The efficacy
of stroke rehabilitation: a qualitative review. Top Stroke Rehabil. 2003;10(2):1-18.
http://dx.doi.org/10.1310/AQE1-PCW1-FW9K-M01G. PMid:13680515
https://doi.org/10.1310/AQE1-PCW1-FW9K-M...
. One second positive aspect was the inclusion of trials that examined the same
outcome measure - walking speed; this allowed the exhibition of results in weighted mean
difference, which is clinically intelligible. Furthermore, the inclusion of only trials
whose intervention was walking training associated with virtual reality-based training
constraints the results to a specific intervention.
Conclusions
This systematic review provided clinical evidence for the efficacy of the addition of virtual reality-based training to walking training in improving walking speed after stroke, compared with placebo or no intervention. In addition, this review demonstrated that walking training associated with virtual reality-based training was more effective in improving walking speed, compared with non-virtual reality walking interventions. The results are based on a meta-analysis of seven randomized clinical trials with good methodological quality. Clinicians should, therefore, be confident in prescribing walking training associated with virtual reality-based training to improve walking speed after stroke. Other factors, such as clients' values and expectations, clinical expertise, and costs of implementation should also be considered, when deciding on the most appropriate type of intervention for each client.
Thanks to Brazilian funding agencies: the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), and the Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG).
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Appendix 1. Search strategy for the systematic review on the addition of virtual reality-based training after stroke.
Publication Dates
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Publication in this collection
Nov-Dec 2014
History
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Received
19 Dec 2013 -
Reviewed
02 Apr 2014 -
Accepted
01 July 2014